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At the heart of general practice since 1960

A solution to the out-of-hours crisis

After last week's Pulse investigation revealing PCTs have cut the number of GPs on out-of-hours shifts by up to 50 per cent, Dr Krishna Korlipara says a new approach is needed

The new GMS contract marked a watershed in the delivery of out-of-hours care in the UK. With no previous experience and no clear guidance from the Department of Health, PCTs were left to decide for themselves the best way to organise out-of-hours services in their areas.

Different PCTs exercised different choices. Some delegated responsibility to commercial providers who were mainly driven by profit rather than service, and others gave it to GP collaborative services or non-profit organisations such as GP

co-operatives or mutual benefit societies operated by various healthcare workers.

Some PCTs are providing these services in-house, acting as commissioners and providers at the same time, creating

a conflict of interest that could compromise public safety. Some have called for tenders but made decisions anyway based on their own preferences rather than on cost-effectiveness. Others, without even bothering with tenders, just chose the provider they 'liked most'. Inevitably standards of care vary wildly from one area to another, depending on who provides the service and whether local GPs are involved. No wonder the Public Accounts Committee last month called current out-of-hours services 'shambolic'.

The Bolton experiment

All this is in sharp contrast to the pre-2004 situation, when GPs still held their traditional 24-hour responsibility for the care of their patients 365 days a year. Under the GP co-operative model, GPs were able to maintain excellent standards of care through employing one of their own number without relying on locums.

The very first article about a GP co-operative appeared in Pulse almost exactly 30 years ago. It was titled 'The Bolton Experiment' and focused on the first co-op to be established in the UK, following

a nine-month gestational period during which I had to jump through a lot of hoops to galvanise support from my GP colleagues and satisfy the Bolton Family Practitioners Committee that the new project would be viable and better than the commercial service then operating. The rest is history of course; the success of the Bolton experiment inspired 25,000 GPs to set up 270 co-ops by 2002, serving a population of more than 25 million.

Unfortunately the new GP contract means doctors have lost the drive to belong to non-profit making GP co-operatives – and this is what has resulted in the current chaos in out-of-hours services.

CMEDs: the way forward

The concept of collaborative medical services (CMEDs) was born in the aftermath of the new GMS contract to provide new incentives to GPs to work outside normal working hours. CMEDS (Bolton) came into existence in 2004 to keep up with evolving changes in out-of-hours care arrangements. It took over Bolton District Medical Services – the original pioneer GP co-op. The constitution of the CMEDS is similar to a GP co-op in that it is jointly owned exclusively by local GPs and other primary care doctors. But unlike a GP co-op, each doctor has the right to buy at least one share and can buy more as they become available.

As in GP co-ops, doctors who work the shifts that suit them best are rewarded with attractive rates of pay. For example

a doctor working 10pm-8am will earn at least £900 plus pension contributions.

In the case of CMEDS, a shareholder can also share in the financial success of the company as it achieves excellence in the delivery of standards of care. A GP co-op,

by definition, was a company limited by guarantee that could not make a profit.

As we move into an era of practice-based commissioning, CMEDS can offer a forum for local GPs to work together and develop other community-based services for the common benefit of their patients. This is

a totally different picture from a purely commercial enterprise owned by a few entrepreneurs who provide the service as

a means to earn a profit.

If public faith is to be restored in out-of-hours services, the Government should take the initiative and issue guidelines to all PCTs, encouraging them to work with local GPs via this collaborative model. They must act urgently before there is a crisis of public confidence.

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